A newly licensed nurse is caring for a client who requires tracheal suctioning, which is a procedure the nurse has not performed in practice. Which of the following actions should the nurse take?

Ask an experienced nurse to assist with the procedure.

Refuse to take the assignment.

Identify that the task is in the scope of RN practice and perform the suctioning.

Delegate the task to assistive personnel.

Answer and Explanation

The Correct Answer is A

Choice A reason: Asking an experienced nurse to assist ensures the procedure is performed safely while allowing the newly licensed nurse to gain competence. Tracheal suctioning requires sterile technique and skill to avoid complications like hypoxia or trauma. This approach supports patient safety and professional development, aligning with nursing standards.
Choice B reason: Refusing the assignment is inappropriate, as tracheal suctioning is within an RN’s scope of practice. Refusal avoids responsibility without addressing the client’s needs or the nurse’s professional growth. Seeking assistance ensures safe care while building skills, making this choice less effective and unprofessional.
Choice C reason: Performing tracheal suctioning without prior experience risks patient harm, as it requires precise technique to prevent complications like mucosal damage or infection. Without guidance, errors are more likely. Seeking supervision ensures safety and competence, making this choice unsafe and inappropriate for a novice nurse.
Choice D reason: Delegating tracheal suctioning to assistive personnel is inappropriate, as it is a sterile procedure requiring RN-level skills and judgment. Assistive personnel are not trained for invasive procedures like suctioning, which risks complications. This choice violates delegation principles and compromises patient safety, making it incorrect.

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Correct Answer is D

Explanation

Choice A reason: Adding salt to season foods can irritate oral sores in AIDS patients, often caused by candidiasis or herpes. Salt exacerbates pain and delays healing, making this instruction harmful and inappropriate for managing oral discomfort in this population.
Choice B reason: Rinsing with alcohol-based mouthwash worsens oral soreness, as alcohol irritates mucosal lesions common in AIDS. Non-alcohol, antiseptic, or saline rinses are preferred to promote comfort and healing, making this instruction incorrect and potentially painful.
Choice C reason: Eating hot foods can aggravate oral sores, increasing pain and delaying healing in AIDS patients with mucosal damage. Lukewarm or cool foods are better tolerated, making this instruction inappropriate and counterproductive for managing the client’s symptoms.
Choice D reason: Using ice chips numbs the mouth, reducing pain from oral sores during eating for AIDS patients. This non-invasive, soothing intervention is safe and effective, aligning with comfort-focused care for mucosal lesions, making it the correct instruction.

A. The client has a wound dressing saturated with sanguinous drainage after it was reinforced. B. The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied. C. The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication. D. The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter.

Correct Answer is A

Explanation

Choice A reason: Saturated sanguinous drainage post-reinforcement signals excessive bleeding, potentially indicating hemorrhage or poor wound healing. Two hours postoperative, this suggests vascular injury or coagulopathy, requiring urgent provider notification to prevent hypovolemia, infection, or further complications in the surgical site.
Choice B reason: Oxygen saturation of 96% on 2 L/min nasal cannula is normal (95-100%), indicating stable respiratory status. This does not require reporting, as it reflects effective oxygenation post-surgery, with oxygen therapy appropriately supporting recovery without signs of respiratory distress.
Choice C reason: A pain level of 2/10 post-medication indicates effective pain control, not warranting immediate reporting. Postoperative pain management targets comfort (<4/10), and this level suggests successful analgesia, with no evidence of complications like nerve injury requiring provider intervention.
Choice D reason: Urine output of 50 mL/hr is normal (>30 mL/hr) post-catheter removal, indicating adequate renal perfusion. This does not require reporting, as it reflects normal kidney function and hydration status in the early postoperative period, absent other concerning symptoms.

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A newly licensed nurse is caring for a client who requires tracheal suctioning, which is a procedure the nurse has not performed in practice. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has AIDS. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide?

Correct Answer is D

Explanation

A nurse is caring for a client who is 2 hr postoperative. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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